Behavior Analyst Certification Board | Option 3 for Applicants from Non-English Speaking Countries | 1 Updated 02/2020, Copyright © 2018, BACB®

Application for Examination forBoard Certified Behavior Analyst (BCBA)

Option 3 for Applicants from Non-English Speaking Countries1. Before completing an application, you must:2. Review the “Obtain a Credential” section of the BACB website to ensure that you have the CURRENT fees

and have reviewed the CURRENT version of the application, and all of the CURRENT eligibility standards;3. Review the phase-in of the new Option 3 outlined in the October 2015 BACB Newsletter to verify whether

you are still eligible to qualify under this option.4. Complete the required sections of the Application Form (pages 1-4 are application policies and instructions

only – return only the necessary forms, beginning on page 5);5. Submit the required documentation that you have met the eligibility requirements;6. Submit the proper current fees (application fees are not refundable);7. Do not tape or staple any materials together; and8. Maintain a copy of the entire application packet for your records. Once you submit an application packet to

the BACB, it becomes the property of the BACB and will not be returned to you.

FEES - US DOLLARSBCBA Option 3 $ 245.00Insufficient Funds/Returned Check Fee $ 45.00

All fees must be paid by personal check, money order or cashier’s check in United States currency and made out to the Behavior Analyst Certification Board. Application fees are not refundable. Please do not send cash.

Upon approval, you will be instructed to contact Pearson VUE to schedule a testing appointment. Pearson VUE will charge you a test administration fee of $125 when you make this appointment.

Your application must be mailed to: BACB – Exam Applications 7950 Shaffer Parkway Littleton, CO 80127

If you have any questions while completing your applications, please contact us at applications@bacb.com or 720-438-4321.

You should mail your application by a verifiable method of delivery that includes tracking and delivery confirmation. The BACB will respond to your application when it is processed. However, we receive a large volume of mail and cannot confirm receipt of individual packages. The BACB requires original signatures on paper applications. The BACB will not accept applications that are sent by fax or e-mail.

BACB certification provides standards for behavior analysts practicing in the United States and worldwide. We seek to include certificants from throughout the world in our job analysis updates to help ensure that our standards are international in scope. However, the BACB does not assure or guarantee consistency with the standards (educational content, training, and laws) for any country, province or region outside of the United States.

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Application Policies & GuidelinesThe BACB requires all applicants for examination to send their supporting documentation in a single, complete submission. In other words, all documentation of degree, coursework, experience, college teaching, BCBA reviews, CVs, etc. for a particular applicant must arrive at the BACB offices in a single package. Incomplete submissions will incur a $50 fee for the cost of additional processing.

Checks included with applications are typically deposited right away. Your check will probably be deposited before your application is reviewed. If your check has cleared your bank, it is a likely indication that your application has been received. You should allow at least two weeks for processing beyond the date your application is received.

Once your application is approved by the BACB, you will receive specific instructions on how to contact Pearson VUE, our test administration company. Pearson VUE can provide up-to-date information about the availability of testing sites and dates once you are authorized to schedule your appointment.

Please note: Pearson VUE testing appointments may only be scheduled once your application has been approved by the BACB. Appointments are scheduled on a first-come, first-serve basis. We highly recommend applying early to foster timely approval and scheduling of your testing appointment. Individuals whose applications are approved closer to the testing window dates may have limited choices in testing appointments. Approval to take the examination is valid for up to two years from the date your application was approved by the BACB, subject to continued compliance and reporting as required by the BACB Disciplinary Standards.

Email is the BACB’s primary communication mode with applicants. If additional materials are needed to complete your application, we will notify you via email as soon as possible. Checking and responding to your email frequently can expedite your application approval. The BACB is not responsible for messages that are not received in a timely manner due to the applicant’s failure to check email or due to the applicant’s failure to notify the BACB of an email address change. To ensure that important messages from the BACB are not blocked by SPAM and junk email filters, add applications@bacb.com to your address book and BACB.com to your list of safe domains.

If your application is not approved for any reason, such as incomplete documentation, you will not be permitted to sit for the test. It is best to apply well in advance of your desired testing window so that there is adequate time for the BACB to process your application and for you to secure an examination appointment.

Training/Experience Requirements: DefinitionsAll applicants must provide documentation that they meet the degree, training and experience requirements in order for their applications to be approved. This application is for the Doctorate and Experience Option for Applicants from Non-English Speaking Countries and following this page is a checklist for the Doctorate and Experience Option. Please make sure you have the correct application for the option you would like to use. You should use the checklist below to ensure you have included all of the required documentation with your application. Do not include the checklist page with your application.

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Acceptable Degree & Experience: Doctorate/BCBA Review OptionApplicants qualifying under the Doctorate/BCBA Review Option must have a doctoral degree, conferred at least ten (10) years ago, in behavior analysis, psychology, education or another related field (subject to BACB approval and at least 10 years post-doctoral experience practicing behavior analysis. Experience must be verified by three BCBA certificants who complete BCBA Review forms documenting the experience.

Important Note: Effective January 1, 2016, new requirements for this pathway to BCBA certification went into effect. Any application for BCBA-level certification that is received after, or is incomplete as of December 31, 2015 will be subject to these new requirements, found here.

These changes will be phased-in over a longer period of time for applicants in non-English speaking countries who may only be able to sit for the BCBA examination when it is available in their language.

Non-English speaking individuals, for whom a translation of the examination is already available (i.e., Italian, Hebrew, and Spanish), will have until September 30, 2017 to apply for BCBA eligibility under the current Option 3 standards.

Those who wish to take the examination in a language scheduled to be available in the future will have two years after the first available administration of that examination to apply and become eligible through the current Option 3 standards. For example, when the Chinese BCBA examination becomes available in February 2017, Chinese speaking applicants will have until February 28, 2019 to apply and become eligible for the examination under the current Option 3 standards. After February 28, 2019, Chinese-speaking applicants must meet the new version (January 1, 2016) of the standards in order to qualify under Option 3.

Checklist For Doctorate/BCBA Review Option ☐ I have enclosed the application fee for this option, including the late fee, if applicable. See the first page

of this application for fees.

☐ I meet the Degree Requirement: I have enclosed a completed Part B: Degree Requirement providing information about my bachelors and doctoral degrees. I have also enclosed an official university transcript, or other official documentation, confirming that it was conferred at least ten (10) years ago and that the field of study is behavior analysis, psychology, education or another related field (doctoral degrees in related fields are subject to BACB approval).

☐ I have provided the BCBA Review Form to three (3) BCBAs: I have asked three BCBAs to independently complete a BCBA Review Form. None of these individuals is my relative or employee. I have provided each of these individuals with a postage paid envelope addressed to the BACB, or I have collected the forms from these individuals enclosed in sealed (unopened) envelopes. The time frames identified on these forms will combine to identify a total period of at least ten (10) years. These confidential forms will become property of the BACB and will not be made available to me in any form.

☐ I have enclosed Documentation of Professional Practice: I have included a copy of my current CV (curriculum vita) or resume, that is not more than seven (7) pages in length, showing at least ten (10) years’ post-doctoral experience practicing behavior analysis. The CV or resume includes a listing of any certifications or licenses issued by other state or private agencies that I currently hold. Information on my CV or resume regarding certifications, licenses, and experience is consistent with the information that will be provided on the BCBA Review Form forms submitted on my behalf.

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PART A: Applicant Profile

Complete all parts of this application and include all required documentation and attachments. Incomplete applications may not be processed.

Original Application — Complete all parts of applicationI am applying for: ☐ Board Certified Behavior Analyst – Doctorate/BCBA Option

Board Certified ASSISTANT Behavior Analyst – INCORRECT FORM – see form for BCaBA

☐ Check here if you are currently a BCaBA

Check One: ☐ Mr. ☐ Ms. ☐ Mrs. ☐ Dr.

__________________________________ ______________________________ _________ Legal Last Name Legal First Name MI

PLEASE PRINT OR TYPE LEGIBLY. YOU WILL BE REQUIRED TO SHOW PHOTO ID THAT EXACTLY MATCHES THE NAME LISTED ABOVE IN ORDER TO BE ADMITTED TO THE EXAMINATION. THE SPELLING OF YOUR NAME ON THIS APPLICATION WILL ALSO BE USED ON YOUR CERTIFICATE SHOULD YOU PASS THE EXAMINATION. ALWAYS VERIFY THAT THE BACB HAS SPELLED YOUR NAME CORRECTLY ON CORRESPONDENCE AND NOTIFY THE BACB OF ANY NAME SPELLING ERRORS IMMEDIATELY.

Address where the BACB will send all official correspondence. You must notify the BACB immediately if your address changes:

______________________________________________________________ __________________

Street Address Apt/Suite #

_______________________________ _______________________________ __________________ City/Town State (USA) Zipcode (USA)

_______________________________ _______________________________ __________________

Non-USA County/Parish/State Country Non-USA Postal Code

Telephone Number: Work _____________________________ Fax _________________ Home ____________________________ International Dialing Code ____________

Email is the PRIMARY communication mode with you on needed additional materials.

The BACB is not responsible for messages that are not received in a timely manner due to the applicant’s failure to check email or applicant’s failure to notify the BACB of a change in their email address.

Email Address: _______________________________________________________________________

Disability AccommodationCheck if you are requesting an accommodation. You MUST complete the Disability Accommodation Request Form and submit the required documentation. If you check here but do not submit the Disability Accommodation Request Form and the required documentation, your accommodation request will be denied.

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Background InformationThis information is for statistical purposes and will be treated as confidential by the BACB.

Position Title: Check the title that most closely that best describes your position title or career track:

☐ Administrator ☐ School Teacher

☐ Behavior Analyst ☐ Social Worker

☐ Consultant/ Trainer ☐ Speech/Language Pathologist

☐ Professor/Academic Instructor ☐ Student

☐ Psychologist/Therapist ☐ Other ____________

☐ NA/Not Currently Employed/Prefer Not to Answer

Primary Age Group: Check the age group represents the majority of your clients:

☐ Infants ☐ Adults

☐ Children ☐ Geriatric

☐ NA/Not Currently Employed/Prefer Not to Answer

Degree: Check your highest educational degree earned:

☐ Bachelors ☐ Masters ☐ Specialist ☐ Doctorate ☐ Other: _______________________

Primary Emphasis: Check the category that best primary emphasis:

☐ Behavior Analysis ☐ Education

☐ Positive Behavior Support ☐ Medicine

☐ Precision Teaching ☐ Pharmacology

☐ Direct Instruction ☐ Psychology

☐ Organizational Management ☐ Social Work

☐ Behavior Therapy ☐ Counseling

☐ Language Disorders ☐ Other: ____________________________

Professional Credentials: Check all of the professional licenses or certifications that you currently hold:

☐ Licensed Psychologist ☐ Medicine

☐ Social Worker ☐ Occupational Therapist

☐ School Psychologist ☐ Physical Therapist

☐ Marriage & Family Therapist ☐ ABPP Board

☐ Mental Health Counselor ☐ Psychology

☐ Speech Pathologist ☐ Other: ____________________________

☐ None

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Primary Area of Work: Check the area that best describes your client population:

☐ Autism ☐ Education – Special Ed

☐ Other Developmental Disabilities ☐ Education – College

☐ Mental Health ☐ Dependency/Foster Care

☐ Alcohol/Drug Abuse ☐ Families/Couples

☐ Business/Industry/Government ☐ Health

☐ Education - Regular K-12 ☐ Other: _____________________________________________

☐ Not Applicable

Professional Organizations: Check all of the professional organizations of which you are a member:

☐ ABA ☐ AABT ☐ Regional Association ________________

☐ APS ☐ APA ☐ NASP

☐ Div 33 of APA ☐ APBA ☐ Div 25 of APA

☐ CEC ☐ ASHA ☐ NASW

☐ AAMR ☐ ABCT ☐ ASA

☐ CCBS ☐ None ☐ Other: ___________________________

NOTE: The following items are for statistical purposes only and will not affect application review. Completion is optional.

Gender: ☐ Female ☐ Male

Date of Birth: _____________

Ethnicity: ________________

If you have taken a behavior analysis certification examination before, please give the year or years and state:

_______________________________________________________________________________________

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PART B: Degree Requirement

ALL applicants for eligibility to sit for the examination for Board Certified Behavior Analyst MUST verify that they have a minimum of a Bachelors degree and attach documentation of their graduate degree. All degrees must have been obtained from a qualifying accredited institution, as defined here: http://bacb.com/qualifying-institutions/

BACHELORS DEGREE INFORMATIONBachelors Degree: By providing the BACB with the information below, you are confirming that you possess this degree. You do not need to provide a copy of your diploma or transcript for your Bachelors Degree.

Name of Educational Institution: ___________________________________________

Location: ___________________________________________

Date Received: _____________________

DOCTORAL DEGREE INFORMATIONAn official university transcript, or other official documentation, must be attached to verify your highest degree.

See The “Obtain a Credential” Section for information about acceptable degrees to ensure your graduate dregree qualifies.

Highest Degree Obtained: ___________________________________________

Name of Educational Institution: ___________________________________________

Location: ___________________________

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PART C: Eligibility Affidavit

Mandatory Questions☐ Yes ☐ No Have you read, are you in compliance with, and do you agree to continued compliance with all Behavior Analyst Certification Board (“BACB”) rules and regulations, as may be revised, including, but not limited to, the BACB educational and experiential requirements, application standards, application FAQs, disciplinary and appeal standards, renewal, recertification, reentry rules, fee and application requirements? Applications with “NO” responses will not be processed.

☐ Yes ☐ No Do you have a physical or mental condition or addiction to any substance that could impair competent and objective professional performance of behavior analysis services and/or jeopardize public health and safety? Explain any “YES” responses on an attached sheet of paper.

☐ Yes ☐ No Have you been subject to an investigation or disciplinary action by a health care organization, professional association, governmental entity or regulatory or licensing agency or authority, and/ or have you ever been convicted, found or entered a plea of guilty, or are you presently being investigated or charged with any felony or misdemeanor directly relating to behavior analysis services or public health and safety? On an attached sheet of paper you must identify ALL investigations, allegations, charges and outcomes. Attach documentation if available.

NOTE: If you are currently imprisoned, on probation or parole or a case is being appealed, the BACB may deny certification or recertification until three (3) years following the exhaustion of your appeal, completion of probation or parole, or final release from imprisonment, whichever is later.

YOU MUST NOTIFY THE BACB IMMEDIATELY IF ANY CIRCUMSTANCES ARISE THAT WOULD MODIFY A RESPONSE YOU HAVE PROVIDED ON THIS APPLICATION.

BACB Certificant Information Release PolicyThe BACB provides an internet registry listing CERTIFICANT NAME, CITY, STATE/PROVINCE and COUNTRY.

The internet registry allows users to search for certificants by zip code. Users are able to email certificants from a link in the registry. The user is not given the certificant’s actual email address.

☐ Check here if you DO NOT want to be emailed from the registry. Unless you check this space, users will be able to email you from the internet registry.

It is the intention of the BACB Board of Directors to provide you with access to important information regarding training, educational, job, and research opportunities. To achieve this goal, the BACB may provide your name and address to organizations interested in notifying you of behavior analysis educational programs, events, jobs, surveys or research.

☐ Check here if you DO NOT want your name and address included in these lists.

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The Behavior Analyst Certification Board agrees to process this application subject to your agreement to the following terms and conditions:

1. To read, remain current, be bound by and comply with all BACB rules relating to eligibility, certification, renewal, recertification, reentry and conduct, including, but not limited to, payment of applicable fees (which are non-refundable), demonstration of educational and experiential requirements, satisfaction of renewal and continuing education requirements, compliance with the BACB disciplinary standards, and compliance with all BACB documentation and reporting requirements, as may be revised from time to time, with notice of revisions to be published in the BACB Newsletter and/or on the BACB website. You are responsible for checking the BACB website regularly for changes, revisions and additions to the standards and you are deemed to have received notice of the changes, revisions and additions within 30 days of the date they are posted on the website.

2. It is the policy of the BACB not to release candidate information provided and contained in BACB applications, unless such information relates to pending or final disciplinary actions and/or is requested by a state or federal licensing authority, agency, court of law, or otherwise properly subpoenaed. The BACB does offer an online Certificant Registry and also licenses use of the BACB mailing list/labels to third parties. By applying, you authorize the BACB to publish and/or release your certification or recertification status on the Certificant Registry (along with contact information and your willingness to serve as a supervisor, if applicable) and you authorize the BACB to publish and/or release any final or pending disciplinary (professional conduct) decisions to state licensing boards or agencies, other health care organizations, professional associations, employers or the public. Unless there is a pending or final disciplinary action against you, the BACB will allow you to opt out of appearing on the Certificant Registry; at any time, you may opt out of the BACB mailing list/labels.

3. To hold the BACB harmless, and to waive, release and exonerate the BACB, its officers, directors, employees, committee members, panel members and agents from any claims that you may have against the BACB arising out of the BACB’s review of this application, or any future applications relating to eligibility for certification, renewal, recertification or reinstatement, conduct of the examination, issuance of a disciplinary (professional conduct) sanction or decision, and/or publication or third-party disclosure in accordance with Clause 2 of this Agreement.

4. To accurately identify to others (including employers and clients) that BACB certification, if granted, acknowledges that you have met the BACB’s minimum standards, but does not warrant or guarantee your competence to provide professional services, and to indemnify the BACB from and against any liability that may arise from the BACB’s issuance of your certification or recertification and your professional practice.

5. To only provide information in your application to the BACB that is true and accurate to the best of your knowledge. You agree to revocation or other limitation of your certification, if granted, should any statement made on this application or hereafter supplied to the BACB be found to be false or inaccurate or if you violate any of the rules or regulations of the BACB.

6. If this application is NOT complete, it will be returned and invoke a $50 fee.7. Once your application is approved by the BACB, you will have two (2) years from the approval date to sit for

and pass the examination. If you do not take and pass the examination within two years you will need to reapply under the then-current standards and pay the then-current application fees.

Mandatory Certification Processing Agreement

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8. In the event that you fail the examination and want to retake the examination, you must do so within two years from your original approval date, or you will no longer be deemed eligible for certification, and must reapply and pay all fees in order to reestablish your eligibility.

9. To abide by the following testing conditions:• The BACB and Pearson VUE reserve the right to refuse admission to any BACB examination if you do

not have the proper identification, or if administration has begun. If you are refused admission for any of these reasons or fail to appear at the test site, you will not be entitled to a refund of the application or administration fees. During the examination, the use of scratch paper, calculators, or reference to textbooks or notes is prohibited and you are not allowed to remove any examination materials from the administration room.

• The BACB examinations are only offered to individuals who are seeking BACB certification or recertification, and for no other purpose. The BACB examinations and individual questions are copyright protected and highly confidential trade secrets. Any disclosure or reconstruction of test questions and content shall be a violation of BACB rules and subject to damages including, but not limited to, the cost of replacing the compromised question(s) and reconstruction of the examination, if advisable, at the discretion of the BACB.

• Proctors are authorized to maintain a secure and proper test administration. You may not communicate with other examinees during the examination. Any irregular, disruptive, inappropriate or suspected cheating behavior by you may result in your relocation or removal from the examination site and/or a refusal to release your examination scores; in such event, your examination and administration fees will not be refunded or deferred.

• The examination is designed to determine whether applicants possess sufficient knowledge to become certified. The examination is not designed to rank order those examinees who achieve passing scores. Consequently, the BACB does not provide numeric scores to passing candidates.

• Failing candidates will be provided with numeric scores and with an indication of their performance level in each of the major examination content areas. This information is provided solely for the purpose of providing applicants with an indication of areas where they may wish to complete additional study. You are not and will not be allowed to review your examination, appeal your examination scores or individual examination questions, contest examination content, require public release (via subpoena or other legal action) of examination content, or request alternative methods of scoring your examination.

10. You may not use any references to Board Certification or the examination to become Board Certified unless you are actively certified.

By submitting this application, you acknowledge and affirm that you have carefully read and understand these rules and requirements and that you agree to abide by these terms.

Signature: _______________________________________________________________________________

Printed Name: ____________________________________________________________________________

Date: _______________________________

Mandatory Certification Processing Agreement

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BCBA Review Form For Doctoral Option

Applicant’s Name: ________________________________________________________________________

Applicant’s Signature:______________________________________________________________________

By signing above, the applicant for certification requests and authorizes the reviewer to release the information requested by the BACB.

BCBA Reviewer’s Name: ______________________________ BCBA Account ID #:________________

Note to Reviewer: in answering the questions below and in agreeing to keep this information confidential to all but the BACB, you are bound by the BACB’s Professional Disciplinary Standards that prohibit false or misleading statements in applications to the BACB.

Identify your relationship with the applicant. If the applicant is a relative or employer, you may not complete this form: _______________________________________________________________________________

In what context have you been familiar with the applicant’s work? List the settings in which you have observed the applicant’s work. _________________________________________________________________________ _________________________________________________________________________

Identify the types of consumers the applicant has experience working with (e.g., persons with autism, persons with developmental disabilities, managers, persons with traumatic brain injuries, teachers, etc.)? ______________________________________________________________________________________

Identify the period of time from _____________ to _____________ that you are able to confirm (either personally or through review of applicant’s documentation) applicant’s experience with behavior analysis as a primary function of applicant’s employment or consultation activities.

Are you aware of any current or recent (during the last 3 years) acts or omissions by the applicant that may be construed as not complying with the BACB’s Professional Disciplinary Standards? If so, please explain. Attach a separate page if necessary. ________________________________________________________________

A Separate BCBA Review Form Must Be Completed By Each BCBA At Least Three BCBA Review Forms Must Be Submitted

SECTION A - Must be completed by applicant

SECTION B - Must be completed by reviewer

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Check Yes or No for the Questions below.

Question Yes No

1.Do you believe the applicant has a good understanding of the basic principles of behavior analysis in accordance with the current BACB Task List?

2.Does your direct knowledge of programs and interventions written and/or developed by the applicant show correct representation of ABA techniques and procedures in accordance with the current BACB Task List?

3. Does your direct knowledge of the applicant’s direct interactions with consumers show the correct use of basic ABA techniques and procedures in accordance with the current BACB Task List?

4.

Based on your direct knowledge of the applicant’s programs, interventions and interactions, are you of the opinion that the applicant has a firm understanding of, and ability to practice in accordance with the task areas identified on the current BACB Task List?

5.Are you aware of any investigations (employer, state agency or police), litigation, charges filed, or adjudications (civil or criminal) involving the applicant during the last five (5) years?

6. Do you recommend this applicant for eligibility to sit for the BCBA certification examination? If your answer is “No,” please explain on a separate page.

Attestation: I have completed this review without consultation with the applicant and independent of any other BCBA who may be reviewing the applicant. I agree to keep the contents of this review confidential to all but the BACB, and not provide a copy to the applicant unless it is in a sealed (unopened) envelope.

Signature of the BCBA Reviewer: _____________________________________________________________

Date Signed: ______________________________